Conception - pregnancy - delivery

1
st
week

(Early) neonatal period :
birth 1
st
week

late neonatal period :
birth 4
th
week
Survive from death
Survive from sequallae
Cause of Death
death proportion (%)
Birth Asphyxia 21.1
Birth Trauma 10.6
Tetanus neonatorum 14.1
Sepsis,meningitis 7.2
Pneumonia 19.0
Diarrhae 1.5
Prematurity 10.3
Congenital malformation 11.1
Others 5.1
Injuries of newborn associated to the delivery
Excluded to :
Amniocenthesis injury
Intra uterine transfusion
Fetal venous puncture
Injuries related to resuscitation
The fatal type significantly
due to 7 obstetric practice
and technology 3,7 per 100,000
live birth.
The non fatal type varies
the injury type
2-7 per 1000 live births
Necessitates careful physical
+ neurologic examination
1. Primiparity
2. Small maternal stature
3. Maternal pelvic anomalies
4. Prolonged or extremely rapid labor
5. Deep transverses arrest
6. Oligohydramnion
7. Abnormal presentation
8. Use of mid forceps or vacuum extraction
9. Version and extraction
10. VLBW infant or extreme prematurity
11. Fetal macrosomia
12. Large fetal head
13. Fetal anomalies
1. Soft tissue injuries
2. Head surface
3. Neck and shoulder
4. Extremity
5. External genital
6. Intra abnominal injuries
7. Intra cranial injuries
A. Head and neck injury
B. Cranial nerve, spinal card and peripheral
nerve injuries
C. Bone injuries
D. Intra abdominal injuries
E. Soft-tissue injuries
Erythema
Petechiae
Ecchymosis and hematoma
Aberration and laceration
Subcutaneus fat necrosis
Caput succedaneum
Vacuum caput
Subconjunctival bleeding
Facial bone fracture
Petechiae
Hematoma
Ecchymosis
Laceration
Pheripheral facialis nerve parese
Brachial plexus
Paralysis/Parese Duchene-ERB
Paralysis/Parese Klumppke
Paralysis/Parese nerve phrenicees
Clavicula fracture
1. Associated with fetal monitoring
2. Extracranial hemorrhage
a) Classification :
1. Cephalhematoma
2. Subgaleal hematoma
3. Caput succedaneum
4. Vacuum caput
b) Management :
3. Intracranial hemorhage
1. Cranial nerve injury
facial nerve injury

2. Cervical nerve root injuries
a. Phrenic nerve palsy (C3,4 or 5)
b. Brachial plexus injuries
C5-6 roots injuries
80% of plexus brachialis injury
Biceps reflex (-)
Radial reflex (-)
Moro (-)
Grasp reflex (+)
Pathognomonis : Porter sign
Radiology : DD/bone fracture
Physiotherapy :
Fixation : arm abduction 90, shoulder exorotation wrist 90,
lower arm suppination extention of hand.
C7 th1 roots injuries
2,5% of brachial plexus injuries
Internal arm muscle disturbances
Biceps reflex (+)
Radial reflex (+)
Moro reflexs (-) / assymetry
Grasp replex (-)
Incase of sympathic nerve included :
Horner Syndrome (ptosis,myosis,
ecophthalmos,head/facial anhydrosis
homolateral
Physiotherapy : netral position
C3,4,5 root injuries
Respiratory distress, cyanosis, tachypnea
Radiology :
* diaphragma elevation
* shift of mediastinum & heart
Fluoroscopy
* seesaw movement
* Shiftened of mediastinum
Therapy : NICU ventilator, surgery
Breech delivery
Male : scrotal
capsula testis
Female : labia majora injury
Edema
aberration
hematoma
hematocele
Conservative therapy
Rare
Malpresentation
Soft tissues
Humerus fracture
Femur fracture
Coxsae dislocation
Radial articulation dislocation
Extremely rare
Uncovered by bone tissue
Liver
Spleen
Adrenal gland
+ Intracranial haemorrhage
+ Cause : * mechanical
* hypoxic
* combined
+ Hypoxic trauma more difficent
to be avoided
+ CNS immaturity
Cerebral circulation
autoregulation
+ Classification
1. Subdural
2. Primary subarachnord
3. Intracerebral
4. Periventricular - intraventricular
Hypoxic birth trauma :
HIE necrosis
cerebral cortex atrophy
periventricular leucomalacia
basal ganglia degeneration

Prognosis : Severity of encephalopathy
Serve 40% death,
10% neurological disturbance,
mental retardation, vision disturbance,
hearing impairment, celebral paresis
Anomalies occured since the gestation
period

Classification :

Major
Minor

Genetic
Non genetic

w Chromosome aberration
w Single mutant gene
w Multifactorial inheritance
~ Numerical Trisomy
Tetrasomy
Monosomy

~ Structural Deletion
Inversion
Translocation
~ Autosome dominant
~ Autosome Recessive
~ X-linked inheritance
~ Thalassemia
~ Sickle cell anemia
~ Haemophilia
~ Cystic fibrosis
~ G6PD deficiency
1. Infection : TORCH
2. Environment : Mercury
3. Drug-poison : ~ Thalidomide
~ Warfarin
4. Habit : ~ Alcohol
~ Retinoic acid
5. Nutrient : ~ Folic Acid
6. Mechanical : ~ Deformity due to amniotic band
Cause Inc :
Genetic abnormalities
- Multifactorial inheritance 0.6 CHD, anencephaly
- Single mutant genes 0.1 Polycystic Kidney
- Chromosomal abnormalities 0.1 Down syndrome
- Uncertain inheritance 0.3 Polydactyly

Uterus Factors 0.1 Breech presentation
amniotic bands
Drugs taken by mother 0.01 Warfarin
Maternal conditions 0.1 D.M
Unknown etiology 1.1 Omphelocele
Total 2.41%
Figure 3. An initiating malformation may give rise to secondary
deformation or disruption , and vice versa. The terminology,
such as malformation sequence, refers to the initiating defect and
its consequences. When the nature of the initiating defect is
unresolved between the three types, the term malformation is
generally utilized.
Malformation
Disruption Deformation
Nature of Problem
Deformation
(mechanical)
Malformation
(poor formation)
Disruption
(destructive)
Multiple
localized
defect
Single
Localized
defec
Malformation
syndome
Malformation,
malformation
sequence
Deformation,
deformation
sequence
Disruption,
disruption
sequence
Malformation
association
Figure 4. Most patient with multiple structural defect will fall into one
of there five categories. The prognosis management, and recurrence risk
counseling may vary considerably among these vategories.
SINGLE LOCALIZED ANOMALY
in early morphogenesis
SECONDARY ANOMALIES
PATTERN OF MULTIPLE ANOMALIES
in later morphogenesis
Figure 1. Sequence designates a single localized anomaly plus its
subsequently derived structural consequences, as depicted above.
Non genetic type :
e Optimal perinatal services
e Rehabilitation
e Operative surgery
e Supportive treatment
e Pra-conseptional conselling

Genetic type :
` Optimal perinatal service
` Rehabilitation
` Operative surgery
` Supportive treatment
` Genetic councelling
` Pra-conceptional councelling